Plan of care
Formal Definition
A documented, organized statement of the clinical problems being addressed and the corresponding interventions, investigations, and goals for each problem; typically organized by problem list in the assessment and plan section of a progress note; communicates clinical thinking to the entire care team and sets measurable targets for each active issue.
How It's Used on the Ward
"The plan" or "A and P" — the assessment and plan section of a note listing each problem and what you are doing about it.
Example
""Plan of care, problem-based: #1 COPD exacerbation — continue albuterol nebs q4h, IV methylprednisolone 40mg daily, azithromycin day 2 of 5; target SpO2 >92%; SBT tomorrow if breathing improved. #2 Type 2 diabetes — hold home metformin, sliding scale insulin, target glucose 140–180. #3 Hypertension — hold home lisinopril while IV fluids running; resume at discharge.""
Clinical Context
Problem-based plan: organize by numbered active problems, not by organ system or specialty. Each problem gets: assessment (what do we think is happening?), plan (what are we doing?), goal (what is success?), contingency (what if this does not work?). Common student error: listing interventions without reasoning — "check CBC" without "to evaluate for evolving infection given persistent fever." Plan documentation is both clinical communication and medicolegal record — vague plans are undefendable. Plan of care discussions with patients: CMS requires daily interdisciplinary team communication with patient/family about plan of care in IPPS-paid hospitals.
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